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Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Interventions

Acute pain Short term: Establish rapport To gain trust Short term:
Subjective: secondary to
surgical After 4 hours of nursing Emphasize ordered diet To encourage The patient’s pain
The patient operation interventions, the patient not to eat scale decreased
may Monitor vital signs
patient’s pain scale will untolerated food 10/10 to 5/10
verbalized: Provide comfort measure
decrease 10/10 to 5/10
To obtain baseline Long term:
“My Encourage deep breathing
Long term: data
incision is The patient’s pain
Provide safety measure
hurts” After 1 day of nursing To satisfy the diminished and
interventions, patient’s Develop communication confinement of performed activities
Objective:
pain will diminish and patient like side movements
review
The patient perform activities like and leg bending
procedures/expectations and To inhibit pain
manifested : side movement and leg
tell client when treatment
bending To prevent from
-irritability will hurt
injury

-impaired Administer analgesics as


To alter pain and
physical indicated to maximal dosage
diminish emotional
mobility as needed
stress

-disturbed
To reduce concern
sleep
of unknown and
pattern
associated muscle

-facial mask tension

-diaphoresis To maintain
acceptable level of
-restlessness
pain.
-facial
grimaces

Assessment Nursing DiagnosisPlanning Nursing Rationale Evaluation


Interventions

Hyperthermia Short term: > Establish rapport >To gain trust Short term:
S> The
patient After 4 hours of nursing > Monitor vital signs >To obtain baseline The patient
may
manifest: interventions the patient data maintained core
> Monitor body
will maintain core temperature within
-headache temperature every 4 > To evaluate
temperature within normal range
hours or more often if effectiveness of
O> The normal range
indicated interventions Long term:
patient
Long term:
may > Loosen patient’s >To promote heat The patient was free

manifest: After 1 day of nursing clothing loss through from complications


interventions the patient radiation and such as irreversible
-increase in and remove blankets
will be free from conduction brain damage and
body > Apply ice bags to
complications such as acute
temperature >To promote heat
irreversible brain damage axilla or groin and do
above loss through
and acute renal failure TSB
normal evaporation
> Administer
range >To reduce fever
antipyretic as ordered
-flushed > Changes LOC
> Observe patient for
skin, warm may result from
confusion or
to touch tissue hypoxia
disorientation
-tachycardia >Offering patient
> Determine patient’s
-seizures or liquids he prefers
preference for liquids
convulsions promotes adequate
> Keep liquids at hydration
bedside and within
> To allow patient
reach
easy access
> Monitor intake and
> To identify
output accurately
changes and
> Administer I.V fluid progress of the
as ordered treatment

> Give patient oresol >These measure


prevents excessive
>Provide supplement
loss of water,
oxygen
sodium chloride and
> Maintain bed rest potassium

> Provide high-caloric > To replace loss


diet, tube feedings or fluid and
parenteral nutrition electrolytes

> To offset increase


oxygen demands
and consumption

> To reduce
metabolic demands

> To meet increased


metabolic demands

Assessment Nursing Planning Nursing Rationale Evaluation


Diagnosis Interventions

Hypothermia Short term: > Establish rapport >To gain trust Short term:
S>O
After 3 hours of nursing > Monitor vital signs >To obtain baseline The patient
O> The
interventions the patient data displayed core
patient may > Remove wet
will display core temperature within
manifest: clothing and prevent > These measures
temperature within normal range
pooling of antiseptic protect patient from
reduction in normal range
solutions under client heat loss Long term:
body
Long term: in OR
temperature > To promote heat The patient

below After 1 day of nursing > Wrap in warm demonstrated


>Surface rewarming
normal range interventions the patient blanket behaviors to monitor
can lead to
will demonstrate and promote
-shivering > Avoid use of heat rewarming shock
behaviors to monitor and normothermia
clamps or hot water due to surface
-cool skin promote normothermia
bottles vasodilation

-pallor
>Administer > To avoid

-slow medications to prevent increasing in


capillary shivering temperature
refill
>Use hyperthermia > To warm patient
-cyanotic blanket
> To prevent
nail beds
>Administer fluids hypovolemic shock
- during rewarming
>To reduce
hypertension
> Keep client quiet potential for
-tachycardia fibrillation in cold
> Provide well-balance
heart
high calorie diet
> To replenish
> Perform range-of-
glycogen stores and
motion exercises,
nutritional balance
provide support hose,
reposition, do > To reduce
cough/deep breathing circulatory stasis
exercises, avoid
> impaired
restrictive clothing
circulation can
> Protect skin by result in severe
repositioning, applying tissue damage
lotion and avoid direct
> To provide heat
contact with heating
appliance or blanket

> Provide patent


airway with
humidified oxygen
when used

Assessment Nursing Planning Nursing Rationale Evaluation


Diagnosis Interventions

Anxiety related Short term: > Establish rapport >To gain trust Short term:
S> The to situational
patient crisis After 3 hours of nursing > Monitor vital signs >To obtain baseline The patient
may
manifest: interventions the patient data verbalized awareness
>Listen attentively;
will verbalized of feelings of anxiety
- concerns allow patient to >To allow patient to
due to awareness of feelings of express feelings identify anxious Long term:
change in anxiety verbally behaviors and
The patient appeared
life event discover source of
Long term: >Identify and reduce relaxed and reported
anxiety
- fear as many environment that anxiety was
After 1 day of nursing
stressors > Anxiety reduced to a
- nausea interventions the patient
commonly results manageable level
will appear relaxed and >Provide accurate
- abdominal from lack of trust in
report anxiety is reduced information about the
the environment
pain to a manageable level situation
>Helps the patient
- fatigue > Provide comfort
what is reality based
measures like back rub
- sleep
and soft music >To decrease
disturbance
autonomic response
>Use cognitive
- urinary to anxiety
therapy
hesitancy
>To correct faulty
>Refer patient to
O> The catastrophic
professional mental
patient interpretations of
health resources
may physical symptoms
manifest:
>To provide
- poor eye ongoing mental
contact health assistance

- extraneous
movement

-
restlessness

- irritability

- anorexia

- insomnia

- impaired
attention

Trembling,
hand
tremors
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Interventions

Fatigue related Short term: >Establish rapport >To gain trust Short term:
S>O to physical
condition After 4 hours of nursing >Monitor vital signs >To obtain The patient
O> the
intervention, the patient maintenance data demonstrated
patient >Evaluate the need for
will demonstrate an increase energy
manifested: individual assistance >To determine
increase energy output output without
and discuss lifestyle degree of fatigue
-Pale skin with presence of fatigue presence of fatigue
changes imposed by
>Enhance
-Impaired Long term: fatigue state Long term:
commitment in
physical
After 3 day of nursing >Establish realistic promoting optimal The patient
mobility
intervention, the patient activity goals with outcomes performed activities
-Irritability will perform activities of client of daily living and
>To indicate the
daily living and participate in desired
-Weakness >Instruct client in need to alter activity
participate in desired activities at level of
ways to monitor level
-Pain= 5/10 activities at level of activities
responses to activity
ability
-Activity and significant signs
intolerance and symptoms

-stress

Assessment Nursing Planning Nursing Rationale Evaluation


Diagnosis Interventions

Sexual Short term: >Establish rapport >To gain trust Short term:
S > The Dysfunction
patient may related to altered After 4 hours of nursing >Monitor vital signs >To obtain The patient
verbalized: body structure interventions the patient maintenance data identified stressors in
and function > Obtain sexual
-problem will identify stressors in lifestyle that
history including usual >To maximize
such as loss lifestyle that may contributes to the
patterns of functioning communication and
of sexual contribute to the dysfunction
and level of desires understanding
desire dysfunction
Long term:
> Be alert to >Sexual concerns
- inability to Long term:
comments of client are often disguised The patient
achieved
After 3 day of nursing as humor, sarcasm, verbalized
desired > identify current
interventions the patients or offhand remarks understanding of
satisfaction stressors in individual
will verbalize individual reasons
situations > These factors may
-conflicts understanding of > Avoid making value be producing enough for sexual problems
involving individual reasons for judgments anxiety to cause
values sexual problems depression
>Establish therapeutic
O> the nurse-client > They do not help
patient relationship the client
manifested:
>Provide ways to >To promote
-alteration obtain privacy treatment and
in facilitate sharing of
relationship sensitive information
with SO
>To allow sexual
-Change of expression for
interest in individual between
self and partners without
others embarrassment

Assessment Nursing Planning Nursing Rationale Evaluation


Diagnosis Interventions

Risk for Short term: >Establish rapport >To gain trust Short term:
S> O infection
secondary to After 4 hours of nursing >Monitor V.S. >To obtain baseline The patient
O> the surgical interventions, the patient data identified and
patient incision >Note signs and
shall identify and demonstrated
manifested: symptoms of sepsis >To reduce
demonstrate intervention interventions to
complication and
-Weakness to prevent infection >Provide wound prevent risk of
monitor for
healing such as infection
-Pallor Long term: infection
cleaning of wound
Long term:
-with dry After 1 day of nursing >To reduce risk for
>Provide care, change
and intact interventions, the patient infection The patient doesn’t
dressing as needed
dressing on will not have infection experience infection
>To promote
the area. >Encourage increase
healing to the
intake of Vitamin C
-Pain over incision

the incision >Encourage deep


>To prevent
breathing exercise
-Irritability infection to increase
immune resistance
-Presence of
intact >To increase

dressing healing of wound


-Impaired
physical
mobility

-diaphoresis

-fever

-seizures

Assessment Nursing Planning Nursing Rationale Evaluation


Diagnosis Interventions

Risk for fluid Short term: >Establish rapport >To gain trust Short term:
S > The volume deficit
patient may After 4 hours of nursing >Monitor vital signs >To obtain The patient
manifest:
interventions the patient maintenance data identified risk factors
> Encourage increase
- thirst will identify risk factors and appropriate
oral fluid intake > To replace loss
and appropriate interventions
-weakness fluids
interventions > Provide
Long term:
O> the supplemental fluids as >Prevents peak in
Long term:
patient ordered fluid level The patient
manifested: After 3 day of nursing demonstrated
> Monitor intake and >To ensure accurate
interventions the patients behaviors or lifestyle
-decrease output picture of fluid
will demonstrate changes to prevent
urine output status
behaviors or lifestyle > Provide safety development of fluid
-sudden changes to prevent measures > Confusion can volume deficit
weight loss development of fluid lead to accidents
> Encourage the use of
volume deficit
-decrease oresol >To replace loss
skin turgor electrolyte.

-dry mucous
membranes

- sunken
eyeballs

-change in
mental state